What is Form UB-04?
The CMS-1450, or UB-04 form, is a standardized medical claim form used by healthcare facilities such as hospitals and nursing homes. This form allows providers to submit essential billing details to insurance companies, including Medicare and Medicaid, for reimbursement. By including comprehensive information about the services rendered and the associated charges, the CMS-1450 ensures accurate and prompt payment. Filling it out correctly is vital for healthcare providers to prevent reimbursement delays and potential audits.
What is Form UB-04 used for?
Form UB-04 is essential for healthcare billing. Here’s what it’s used for:
- Billing Reimbursement: Submitting claims for care received by patients to insurance providers, including Medicare and Medicaid.
- Detailed Information: Offering detailed descriptions of services provided and associated charges.
- Comprehensive Record: Keeping a complete record of all reimbursable care, including necessary revenue codes for the payer.
How to fill out Form UB-04?
- 1
Identify the Claim Type: Choose between inpatient or outpatient claim.
- 2
Complete Claim Details: Fill in Blocks 1-5 with provider info, patient details, and claim type.
- 3
List Diagnoses and Procedures: Match diagnoses in Blocks 67A-Q with procedures in Blocks 74 and 74a-e.
- 4
Itemize Services and Supplies: Enter each service and supply in the designated sections.
- 5
Include Revenue Codes and HCPCS Codes: Add these codes for outpatient claims.
- 6
Ensure Accuracy and Completeness: Double-check all fields for accuracy and completeness.
Who is required to fill out Form UB-04?
Institutional providers, including hospitals and nursing facilities, are responsible for completing Form CMS-1450.
After completion, the form is used by these providers to bill Medicare fiscal intermediaries and Medicaid State Agencies for services rendered.
When is Form UB-04 not required?
Form UB-04 is not necessary for providers with fewer than 25 full-time equivalent employees billing a Medicare Administrative Contractor. It’s also not required for roster billing, Medicare demonstration projects, or when multiple primary payers are involved in MSP claims. Providers who do not address exception requests may face claim denials.
When is Form UB-04 due?
The deadline for Form UB-04 is within 12 months from the date of service. This timely filing period is calculated using the "From" and "Through" dates on the claim. The "Through" date is the one used to determine if the claim is filed on time.
How to get a blank Form UB-04?
To get a blank Form UB-04, visit our website and select the Fill Form option. The form will load directly in our editor, ready for you to fill out. Remember, PDF Guru aids in filling and downloading but not filing forms.
How to sign Form UB-04 online?
To validly sign the Form CMS-1450 (UB-04), you need a handwritten signature that includes your first and last name, along with any relevant credentials. Remember that electronic or digital signatures are not acceptable. After filling out the form using PDF Guru, you can download it for your records. Be sure to check for any updates related to the form before submission, as PDF Guru does not support the submission process.
Where to file Form UB-04?
To submit the Form CMS-1450, also known as the UB-04 form, mail the original completed form. Remember, photocopies are not accepted.
Address the form to the Medicare fiscal intermediary or the Medicaid State Agency based on your provider situation. Ensure it reaches the correct destination for processing.
